What is the initial approach to a patient presenting with dizziness?

Initial Workup of Dizziness

The initial approach to dizziness should categorize patients by timing and triggers—not by symptom quality—into three syndromes: acute vestibular syndrome (continuous symptoms), spontaneous episodic vestibular syndrome (recurrent unprovoked episodes), or triggered episodic vestibular syndrome (symptoms with head movements), as this framework directly guides the physical examination and distinguishes benign from life-threatening causes. 1, 2, 3

Step 1: Classify by Timing and Triggers (Not Symptom Quality)

The traditional approach of asking patients to describe dizziness as "vertigo," "lightheadedness," or "disequilibrium" is unreliable and should be abandoned. 1, 2, 3 Instead, focus on:

Triggered Episodic (Seconds to Minutes with Head Movement)

• Brief episodes triggered by rolling over in bed, looking up, or bending down strongly suggest BPPV 1, 4
• Perform the Dix-Hallpike maneuver immediately—this is both diagnostic and guides treatment 5, 4
• A positive Dix-Hallpike (characteristic nystagmus with vertigo) has 94% specificity for peripheral vestibular disorders 6
• No imaging or vestibular testing is needed for typical BPPV 5, 1

Acute Vestibular Syndrome (Continuous Days to Weeks)

• Constant vertigo, nausea, vomiting, and gait instability lasting days 1, 4
• The HINTS examination (Head Impulse, Nystagmus, Test of Skew) is MORE sensitive than early MRI for posterior circulation stroke (100% vs 46%) when performed by trained practitioners 1
• Critical caveat: 75-80% of patients with posterior circulation stroke have NO focal neurologic deficits, so a normal neurologic exam does NOT exclude stroke 1
• HINTS findings suggesting central cause (normal head impulse, direction-changing nystagmus, or skew deviation) mandate urgent MRI 1, 4

Spontaneous Episodic (Minutes to Hours, Unprovoked)

• Recurrent episodes without positional triggers 1, 2
• Associated headache, photophobia, and phonophobia suggest vestibular migraine 1
• Associated hearing loss, tinnitus, or aural fullness suggest Ménière's disease 1

Step 2: Identify Red Flags Requiring Urgent Imaging

Obtain MRI head without contrast immediately for: 1, 4

• Focal neurological deficits (even subtle)
• Sudden hearing loss
• Inability to stand or walk
• New severe headache
• Abnormal HINTS examination (suggesting central cause)
• High vascular risk patients with acute vestibular syndrome
• Downbeating nystagmus or other central nystagmus patterns

Common pitfall: CT head has low detection rate for posterior circulation infarcts and should not substitute for MRI when stroke is suspected 1

Step 3: Perform Targeted Physical Examination

For Triggered Episodic Symptoms:

• Dix-Hallpike maneuver for posterior canal BPPV 5, 4
• Supine roll test for horizontal canal BPPV 1, 2

For Acute Vestibular Syndrome:

• HINTS examination (only if trained; unreliable when performed by non-experts) 1
• Gait assessment and neurologic examination 1

For All Patients:

• Otoscopic examination 1
• Cardiovascular examination in patients ≥45 years 6
• Glucose testing in all patients 6

Step 4: Limit Laboratory and Imaging Testing

Routine testing has low yield: 1, 6

• Complete blood count, electrolytes, and BUN are low yield unless specific clinical indication 6
• Routine imaging for isolated dizziness yields mostly incidental findings 1
• Vestibular testing should NOT be ordered for patients meeting BPPV criteria without additional atypical features 5

Reserve comprehensive vestibular testing for: 5

• Equivocal or unusual nystagmus findings
• Suspected multiple concurrent vestibular disorders
• Atypical presentations not fitting clear diagnostic categories

Step 5: Initiate Treatment and Plan Reassessment

For BPPV:

• Canalith repositioning procedures (Epley maneuver) are first-line treatment with 90-98% success rates 5, 4
• No medication needed for typical cases 1
• Reassess within one month; treatment failures require reevaluation with repeat Dix-Hallpike 5, 4
• Persistent symptoms after 2-3 repositioning attempts warrant neuroimaging to exclude CNS disorders (found in 3% of treatment failures) 5

For Other Diagnoses:

• Vestibular neuritis: supportive care and vestibular rehabilitation 1
• Vestibular migraine: migraine prophylaxis and lifestyle modifications 1
• Ménière's disease: salt restriction and diuretics 1

Critical Pitfalls to Avoid

• Do not rely on patient descriptions of "spinning" versus "lightheadedness"—focus on timing and triggers instead 1, 2, 3
• Do not assume normal neurologic exam excludes stroke in acute vestibular syndrome 1
• Do not perform routine imaging for typical BPPV 5, 1
• Do not use CT instead of MRI when stroke is suspected 1
• Do not skip the Dix-Hallpike maneuver in patients with positional symptoms 5, 4